by Kimberly Spering, MSN, FNP-BC

Last week, I geared up for a tremendously difficult patient. One that I “inherited,” as a colleague retired. One that was facing the last vestiges of life, fraught with battling metastatic cancer. One that absolutely refused hospice services, as “they gave medication and killed my family members.” No matter that said family was dying of their disease processes… that was the feeling of this patient.

Diagnosed with metastatic cancer in 2014, this patient had endured three major surgeries to remove the cancer… trialed three chemotherapy regimens… and developed hypersensitivity reactions to the last two treatments. A G-tube. A colostomy. TPN infusing via a central port.

I walked into the home on a breezy day, meeting the spouse, three children, significant others, and grandchildren. The patient had been hospitalized and met with one of my inpatient colleagues to discuss goals of care. The feeling was, based on the physical symptoms and disease progression, the patient would not survive one week.

Oh… but, there was a family wedding coming up.

I met the patient four days prior to this wedding. The patient was in-and-out of consciousness, and had significant leaking from the G-tube site — coffee-ground and bilious drainage. Bleeding from the colostomy. The cancer had spread — we knew that. The patient clawed at her port, the G-tube, and the colostomy at times.

I kept my computer shut. Talked with the family about the patient’s goals of care. “‘X’ doesn’t want to go back to the hospital at all. ‘X’ wants to die at home.” We talked about the progression of the cancer. Discussed the symptoms to expect. There was a PCA pump for pain, Ativan for anxiety/agitation. 

The home care RN was absolutely phenomenal. She called me a day later, detailing the issues that they faced… the challenges ahead. Due to a Medicare “rule,” if she transitioned to hospice and had not had TPN for 90 days, the family would be responsible for the $25K cost of the past TPN.

WHAT?!?! No, I still can’t explain it. I did, however, verify this through the hospice coordinator.

I’m proud to say that our hospice team and this home care nurse worked out a plan for the patient… even though she could not officially initiate hospice services.

I spoke with the spouse, getting updates yesterday. From the description, “X” was in the last stages of life… not really responsive, but they interpreted the moans as responding to them.

On Saturday, at 2 PM, the wedding took place. Plans were made to have video streaming into the home, so that the patient could “hear” it. I did not call the family — this was their day to celebrate. And perhaps, mourn.

This was one of the hardest palliative care visits I’ve ever had. However, I’m proud that the whole team (nursing and palliative care) came through to try to help this patient in the last stages of life. I sure hope that the patient did not die on the wedding day… if so, I’m not aware of it. Hopefully, the comfort measures we initiated went a long way to sustain the patient… and family… in these last stages of life.

An update: I read in the newspaper that the patient passed peacefully, with all of her family by her side, the day prior to the wedding. I’m quite certain that she was there in spirit on Saturday.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.